Working With Clients With Dual Diagnosis: The Case of Cathy
Cathy is a 32-year-old, divorced, heterosexual African-American female. She came to her
first initial intake session with complaints of depression with passive suicidal thoughts,
anxiousness, and trouble sleeping. Cathy’s primary concern is that she has been having episodes
three to five times a week during which she reports she cannot breathe, her heart feels like it will
explode, and she feels like the “walls close in.” She states that this has been going on for about a
year, but lately it is getting worse. She self-referred after being prompted by her sister to contact
a social worker. The following is a summary of the initial appointment and assessment we
completed.
Cathy is the oldest of four children (two brothers and one sister), all of whom are married
and live in the same community. Cathy works in a doctor’s office and lives in a one-bedroom
apartment. She is the primary caretaker of her mother, who was involved in a car accident 20
years ago and was left a quadriplegic, going to her home daily to help with her personal hygiene.
Cathy has an arrest history and was incarcerated for 3 years for drug-related charges. She
was charged with possession and intent to distribute. Cathy states that at that time she was
addicted to heroin and using daily. When she completed her prison sentence, she was paroled
and mandated to attend a 1-year outpatient drug treatment program, which she successfully
completed. Cathy reported that she started using cocaine 2 years ago, stating that it helps her do
her fast-paced job better and it keeps her energy up so she can help her mother early in the
morning and late at night. She said no one in her family or at her job knows that she has been
doing drugs. She drinks alcohol daily (two to three drinks). Cathy also takes numerous
medications prescribed to her by her primary care doctor, including an antidepressant and pain
medication.
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© 2016 Laureate Education, Inc.
As we discussed her presenting concerns, multiple issues came up. Cathy shared her
feelings about being her mother’s primary caretaker, stating, “I love my mom, but everyone
expects me to care for her. It feels so unfair, but it’s because I am not married and don’t have any
children.” She said her father does not help with the care of her mother and that all he does is
“hang out.” She feels increasingly frustrated with this added responsibility and resentful that her
father and siblings have relegated this job to her. She also stated that she recently allowed one of
her brother’s friends to move in with her as a favor because he was homeless and had nowhere to
go. She said she believed he was a sweet person who just has had a hard time in life, and she
wanted to help him. She has been supporting him financially over the last month, and she has
become concerned because it appears that he has not made any effort to get a job. She fears she
made a mistake allowing him into her home and worries she will not be able to get him to leave.
Cathy said that she and this new roommate had sex one time when he first moved in. She
said they both got very intoxicated, and she is not sure exactly what happened, but she blacked
out and found him in her bed, undressed. She then told him she had herpes, and he responded
that it had been a “mistake” and that he did not want to have sex with her again because he was
afraid of getting infected. Cathy explained that her ex-husband’s cheating had resulted in this
lifelong disease, and she expressed anger and resentment toward him. She said even though the
herpes is controlled with medication, she feels embarrassed and fears she will never have another
healthy relationship. She also feels used and humiliated by this man now living in her home.
Cathy then shared that when she was 12 years old her father began molesting her. She
stated that she tried to forget what happened to her, but this recent incident with her new
roommate brought it up again. Cathy complained of recent nightmares related to the abuse and
exaggerated startle reactions to other people’s movements.
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© 2016 Laureate Education, Inc.
Plan:
Cathy agreed to go into a 30-day residential treatment program. She completed this
program successfully and, once discharged from the program, resumed individual treatment. Her
trauma and depression were effectively addressed with the combined use of eye movement
desensitization and reprocessing (EMDR) and cognitive behavioral therapy (CBT).
Cathy currently continues in treatment and no longer reports experiencing panic attacks
or nightmares related to her past trauma. Cathy is working on mindfulness and the establishment
of healthy relationships using dialectical behavior therapy (DBT).
Reflection Questions
The social worker in this case answered these additional questions as follows.
1. What specific intervention strategies (skills, knowledge, etc.) did you use to address this
client situation?
Cathy was resistant to seeking treatment for her substance abuse. She initially refused to seek
out help and stated that she knew all about the 12 steps and could quit on her own.
Motivational interviewing was used effectively, and she agreed to go into treatment after
several failures to stop using cocaine on her own. In addition, she had many symptoms
related to her abuse from her father as well as three other incidents (a gang rape, a stranger
rape, and a date rape) she revealed later in treatment. Eye movement desensitization
reprocessing (EMDR) was used effectively to address her flashbacks and negative
associations with this abuse.
2. Which theory or theories did you use to guide your practice?
A combination of theoretical frameworks was used to address each area of concern.
Motivational interviewing was used for her substance addiction, EMDR for her posttraumatic stress disorder, cognitive behavioral therapy for her anxiety/panic attacks and
depression, and lastly dialectical behavior therapy to address her symptoms related to
borderline personality disorder.
3. What were the identified strengths of the client(s)?
Cathy had many strengths, including being a caretaker for her mother, having a job, and
being seen as a very helpful and loving woman by her family and friends.
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© 2016 Laureate Education, Inc.
4. What were the identified challenges faced by the client(s)?
Drug addiction and trauma were the primary challenges that initially needed to be addressed.
Once Cathy had become clean and sober and no longer self-medicated, her trauma symptoms
escalated and became the main focus, so she was at great risk for relapse.
5. What were the agreed-upon goals to be met to address the concern?
Our treatment goals included maintaining sobriety, building a clean and sober network for
support, reducing panic attacks, decreasing flashbacks, decreasing depressive symptoms, and
increasing self-efficacy and mindfulness.
6. What local, state, or federal policies could (or did) affect this case?
After a year of treatment, Cathy became actively suicidal and had to be involuntarily
hospitalized several times. State laws related to involuntary hospitalization were used to
ensure she was in a safe environment.
7. How would you advocate for social change to positively affect this case?
Although Cathy had health insurance, it was minimal, and she had to privately pay for drug
treatment. Her family helped with a deposit of $1,000 but she still owes close to $25,000 to
the drug treatment program and is still making payments. Advocacy is needed on both state
and federal levels to allow for easy access and free drug/alcohol treatment for all.
8. Were there any legal or ethical issues present in the case? If so, what were they and how
were they addressed?
Legal and ethical issues include her family’s desire to know what was happening in treatment
and her need to consent to release of information so I might speak with them when they
called concerned. In addition, within a year of treatment commencing, Cathy was
hospitalized five times as a result of being a danger to herself and holds were written to keep
her hospitalized.
9. Is there any additional information that is important to the case?
Cathy continues to receive treatment in my private practice after 2 ½ years of treatment. Due
to the extent of her sexual abuse and rape, it has taken time to address her symptoms in an
effective manner. Currently Cathy has had no hospitalizations for 3 months and continues to
maintain her sobriety.
Adapted from:
Working with clients with dual diagnosis: The case of Cathy. (2014). In Plummer, S.-B., Makris,
S., & Brocksen S. M. (Eds.). Social work case studies: Concentration year (pp. 22–24, 104–
106). Baltimore, MD: Laureate Publishing. [Vital Source e-reader]